Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCBAL AFB smear positive if any of the following are present:• Cavitations on chest X-ray• Suspected or confirmed MDR-TB• Admitted to a ward or living with immunosuppressed*** 1 individuals.The determination of infectivity of all other BAL smear positive patients should be considered on a case-bycasebasis (clinical/microbiology/public health input).Most children aged less than 10 years with suspected or confirmed TB are not infectious (chapter 8)however, they should be considered infectious if any of the following are present: 77• Cavitations on chest X-ray• Sputum smear positive (not BAL or gastric washings positive)• Suspected laryngeal involvement• Extensive pulmonary infection• Congenital TB and undergoing procedures involving oropharyngeal airway.In addition, patients with extrapulmonary TB in an open abscess or lesion should be considered infectiouswhen aerosolisation of drainage fluid occurs.When a patient with suspected or confirmed infectious TB is receiving healthcare, appropriate infection,prevention and control must be followed to protect employees and other patients from infection.The effective prevention and control of TB relies on:Administrative aspectsImplementation of Standard and Airborne Precautions.6.3 Administrative AspectsAdministrative aspects of the prevention and control of TB comprise early investigation, diagnosis andtreatment by:• A high level of suspicion amongst clinical teams and GPs• Local procedures and guidelines for the management of TB in acute hospitals and community careareas• Staff education and training on current guidelines and procedures• Informing the infection prevention and control team promptly of all suspected and confirmed casesof TB• Collaboration between laboratory, microbiological and clinical teams to ensure rapid testing ofspecimens for acid–fast bacilli (AFB).6.4 Standard PrecautionsStandard precautions are defined as follows: 230Standard precautions are a set of work practices that require all HCWs to assume that allblood, body fluids (except sweat), excretions and secretions from all patients in all settingsare potential sources of infection.***Immunosuppressed is defined as either due to disease or therapies e.g. HIV, individuals receiving >15mg prednisone or equivalentfor more than four week or other immunosuppressive agents for cancer, chemotherapeutic agents, anti-rejection drugs for organtransplantation and TNF-α antagonists or as defined by the attending consultant.-75-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCImplementation of standard precautions constitutes the primary strategy for the prevention of healthcareassociated transmission of infectious agents among patients and healthcare personnel. 230 Full details ofstandard precautions are available in appendix 10. 230Standard precautions include the following work practices and measures:• Occupational health programme• Hand hygiene• Personal protective equipment• Management of spillages of blood and body fluids• Appropriate patient placement• Management of sharps• Management of needle stick injuries and exposure to blood and body fluids• Management of waste and laundry• Safe injection practices• Respiratory hygiene and cough etiquette• Appropriate decontamination of reusable medical equipment• Appropriate decontamination of the environment.Certain transmissible infections require additional control measures to standard precautions to effectivelyprevent transmission. Infectious pulmonary and laryngeal TB require airborne precautions in addition tostandard precautions.6.5 Airborne PrecautionsFull details of Airborne Precautions are available in appendix 10. 230The following section outlines the elements of Airborne Precautions and how they apply to themanagement of a suspected or confirmed infectious TB case.Patient placementIsolation rooms with ventilationSpecially engineered rooms have been designed to limit the spread of certain transmissible infections thatare transmitted via air such as TB. Two designs are suitable for Airborne Precautions:1. Negative pressure isolation room with an ante room. This room has an air handling unitwhich ensures that the air in the room remains at negative pressure to the ante room and thehospital environment2. Neutral pressure design as detailed in HBN 04 Supplement 1. 231Air changes per roomIt is recommended that a minimum of six air changes per hour (ACH) is required for the protection of staff129; 232-234and visitors however, in new buildings 12 ACHs are advised.Isolation rooms can be designed for negative pressure use only but some may have an air handlingunit that can be switched from negative pressure to positive pressure depending on infection controlrequirements. These dual action rooms have been implicated in outbreaks when the incorrect airpressure was selected for a specific infection or patient. This design should not be used in new builds orrefurbishments.Monitoring of ventilation systemAirborne isolation rooms should be monitored continuously by the pressure differential between the roomand the surrounding ward. The monitoring system should alert staff of any failure. 235There should be:• Standard operating procedures (SOPs) in place for changing the air handling settings at wardlevel (if applicable)• SOPs in place for documenting the daily checks on the monitoring system at ward level• Regular engineering checks on the number of air changes and air direction (smoke tests) toensure compliance with best practice 234;235• Regular training for staff in their use• Changing of HEPA filters as directed by manufacturers’ instructions (if applicable).-76-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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